Evidence-Based Practice

Definition

Evidence-based practice is the process by which health care providers incorporate the best research or evidence into clinical practice in combination with clinical expertise and within the context of patient values.

Description

Evidence-based practice evolved out of an explosion of scientific literature and new techniques, medications, and technologies. Medical facilities were faced with rising medical costs and increased litigation, and consumers were calling for accountability in medicine. The medical profession began to seek new ways to insure quality control of medical care. Basing medical procedures and practices on sound research became the means to find the best philosophical, legal, and practical fit for medical institutions and individual patients.

History

Historically, physicians and other health care providers were rooted in authority, basing their practice decisions on their knowledge of the mechanisms of disease and anatomy, their clinical observations, and traditional approaches. In the last half of the twentieth century, this paradigm began to change as medical research increased and the resultant medical literature became more available to physicians, health care professionals, and patients.

Though evidence-based medicine had its beginnings in medical research in the mid-1800s, it was not until 1972, when Archie Cochrane's book, Effectiveness & Efficiency was published in the United Kingdom that the medical profession began to question how it delivered health care and started to take a systematic look at evidenced-based practice. Between 1985 and 1990, an international collaboration of systematic reviews of literature was undertaken in the field of pregnancy, childbirth, and neonatal medicine. In 1992, the Cochrane Centre (now the UK Cochrane Centre) was established to prepare systematic reviews of all areas of health care and to eventually establish a database.

In the United States, the Agency for Health Care Policy and Research was established in 1989 as part of the Department of Health and Human Services. It was reorganized in 1999 as the Agency for Healthcare Research and Quality. It funds grants to universities and other institutions to conduct research that will help health care providers make informed decisions on quality outcomes. This was the basis for modern evidence-based medicine in America.

Evidence-based practice developed by incorporating scientific research with clinical experience and patient preferences. This process looks not just at research findings about new medications, technologies, and procedures but also at how that information applies to a specific clinical setting and an individual patient. In order to do that, the clinical experience of health care professionals and a patient's values and needs had to fit into the health care outcome.

The process

Since organizations for formal systematic reviews of scientific literature have been established, various groups of health care professionals have drafted their own versions of evidence-based practice guidelines. Many professional organizations, such as oncology nurses, surgical nurses, and pediatric health professionals, including psychiatrists, have created resources for their members to use to aid them in this process.

In general, there are six tasks involved in evidence-based practice. They are identifying a problem, researching the literature, critiquing the evidence, formulating recommendations, implementing practice changes, and evaluation.

THE PROBLEM. Needs arise in clinical practice regularly, especially when there is a gap in knowledge regarding new procedures or practices or there is a question concerning the best approach to use in a specific situation. The step from recognizing a need to being able to deal with it hinges on how the practice question is framed.

First, a team of health care professionals involved in the specific area in which the clinical need arises should be brought together to work on the problem. A timetable should be drafted for the complete evidence-based process to take place, giving generous time in the beginning to form the clinical question. The goal of the team at this point is identifying an answer-able question. Spending adequate time here will focus the process and save time later.

Generally, clinical practice needs identify knowledge gaps. They can be questions regarding diagnosis, prognosis, therapy, prevention, or professional education. Diagnosis needs may deal with determining the best tests to use for a specific disorder. Prognosis questions are about determining the use of specific procedures or medications for a patient's best out-come. Finding the best therapy for specific diagnoses is another area of practice needs. Determining the best screening and prevention methods is another area of a knowledge gap. Finally, finding the best teaching strategy for educating patients, family members, or other health care professionals about a new procedure, therapy, or medication is another area of need.

Once the need is identified, the team must form a question that can be answered through research of the scientific literature. The question must be about the patient or clinical setting where the need arises and involve the same specific phenomenon and interventions used in the setting. It also should have a measurable outcome.

RESEARCHING SCIENTIFIC LITERATURE. Once a very specific question is asked, then the team can begin searching the scientific literature. Usually, this will involve several members of the team. Sometimes, this task may fall on one or two professionals. This is a time-consuming step, but essential to the success of the clinical process.

Finding resources is sometimes problematic, especially if the research question is too narrow or involves a new technology that has had little written about it. Good sources of information come from computerized bibliographic databases or topic-based search engines, either as a subscription service to medical professionals or free. Computerized abstract data-bases that identify methods as well as results are another good source.

CRITIQUING THE EVIDENCE. It is essential that what is uncovered in a search of the literature be scientifically sound. It must fit the clinical problem, the clinical setting, and the specific patient population the health care professionals are dealing with. Evaluation of the scientific merit of each study is critical. Not only should results be scrutinized but also the demographics, the methods, and the validity of the study. Special attention should be made to whether the patients in the study were randomly assigned to experimental and control groups and whether other studies replicated the results.

The health care team should evaluate the recom-mendations of the study to determine if they are sound, practical, and clinically relevant to the research question.

FORMULATING RECOMMENDATIONS. Once the literature has been found and evaluated, the evidence-based practice team will need to synthesize all of the recommendations found in the strongest scientific studies. The entire team will need to come together for this step in the process. Not everyone on the team will need to have read all of the literature. The research team members can provide a summary for the team. Multiple results will need to be organized and further evaluated so that a definitive answer about whether one procedure was better than another can be put to discussion immediately.

At this point, practice relevance is the most important factor. Team members will need to answer several questions. Does the evidence support a change in clinical practice? Can the recommendations in the evidence be applied to the current practice setting and patient population? Are there resources for this practice change? Will there be administrative support for this new intervention?

IMPLEMENTING PRACTICE CHANGES. Though there may be a clear recommendation found by the evidence-based practice team, incorporating changes may not be automatic, nor should they be. Implementing a clinical change involves planning and preparation, not just learning how to perform a new procedure. Often, it will involve preparing staff for these changes.

This part of the process consists of three steps: unfreezing, moving, and refreezing.

Unfreezing is selling the staff about the philosophy of evidence-based practice and how it can help their professional lives. Often, even at this stage before an expected change, many evidence-based practice teams will ask for ideas from staff about areas needing change.

The preliminary phase of the moving step identifies expected outcomes from the clinical change that are measurable and relevant to the institution where the change will occur. Baseline data should be collected in order to compare the success or failure of the change. Expected costs should be determined and resources tapped for the change.

The planning phase of moving identifies the setting, what will be changed, how it will be approved, and a time frame for education of the staff about the practice change and implementation. Of critical import during this phase is identifying the barriers to the clinical change and the supporters of it. These barriers can involve administrative support, staff acceptance and compliance, competency of the staff, costs, the cultural climate of the institution, and the timing of the change. If there are other changes going on in personnel or even remodeling, a practice change may be more than the staff can handle at that point.

The implementation phase of moving begins with a trial or pilot change that will assess the practicality of the clinical change in the appropriate setting and patient population. Once the practice change is deemed feasible, then the staff should be educated about the change. Providing a rationale for the change and the evidence behind it will help facilitate staff acceptance of the new procedure.

Refreezing is the last step in the implementation process. Here the practice change is evaluated and a decision is made to broaden its use into the clinical setting. Decisions can also be made to modify how the practice change was conducted or how it was communicated or taught to the staff.

EVALUATION. Further evaluation of the effective-ness of the change in clinical practice is conducted after the change has been implemented. This can be short-term, after only a few weeks or months, or it can be long-term, after a year or more. It can also be done in regular reviews.

Specific monitoring criteria are determined to observe whether the new practice is being done correctly. The effects on staff morale and effectiveness as well as the effects on patient outcomes are also monitored. Costs surrounding this practice change should be observed. At this point, the patient outcomes are compared to the benchmark date collected at the beginning of the evidence-based process.

In addition, staff input should be encouraged throughout implementation and evaluation. It may also be necessary to reward compliance and quality performance with incentives.

Viewpoints

On the surface, evidence-based medicine does seem to value science, technology, and the scientific method with its quantitative results, seemingly removed from the patient and her needs. In application, however, especially in the United States, the patient is at the center of evidence-based practice. The needs generated by a patient's medical situation drives the question that the health care staff addresses and researches.

Recommendations that are made to change clinical practice benefit not only the patient and others like her but also create a better climate in which health care professionals can bring higher quality of care. Old, out-dated methods and procedures can be eliminated and newer, more efficient ones can replace them. Though evidence-based practice deals with one problem or question at a time, it has the potential to streamline and modernize patient care.

Professional implications

Though there are evident advantages to incorporating evidence-based practice into the clinical setting, there are also barriers to compliance. Time and budgetary constraints may be factors. Researching an evidence-based practice question takes time. The process is not a quick or necessarily easy fix. Some questions will take as much as a year or two to reach implementation. Other questions requesting information only may require only a few hours of searching. When staff spend long hours in database searches or in multiple meetings, some administrators worry that time is being taken from their duties on a hospital floor or that they will have to pay overtime for this extra work.

More problematic, however, is the gap in necessary research skills of many nurses and other health care professionals. Some states like North Dakota and Minnesota allow nursing students who have completed an associate's degree to sit for the state's licensing exam for registered nurses. Associate degree programs usually require only two years of study. With limited class time, there may not be room in the curriculum for learning scientific research skills. In addition, many nurses from four-year programs aren't taught these skills nor the ability to analyze scientific literature and synthesize outcomes.

For health care professionals lacking these skills, the task of researching scientific literature may seem overwhelming. They may not even know where to begin looking for data on their research question, much less how to read journal articles critically in order to make judgements about them.

The American Library Association (ALA) recognized this gap, not only among health care professionals, but also among many other professions, including business. Driven by the information explosion of all forms of media and the internet that began in the 1980s, the ALA introduced the concept of Information Literacy in 1989. This was defined as the ability to determine when information was needed and then be able to find the necessary information, critique it, and use it. Even more critical is what the Educational Testing Service has called Information and Communication Technology Literacy or the ability to use all forms of technology and communication tools, and be able to organize the information, evaluate it, and then communicate it to others.

Some schools of nursing are building these skills into their curricula as well as offering workshops and seminars for continuing education credits. Workplace seminars also offer ways to increase information literacy, including familiarizing staff with computerized databases that can provide full articles as well as abstracts. One such database is the National Center for Biotechnology Information (NCBI), part of the National Library of Medicine at the National Institutes of Health, which has 14 million citations. Also, the American College of Physicians (ACP) created the ACP Journal Club that summarizes journal articles and ranks them by relevance.

KEY TERMS

Abstract— A summary of a journal article.

Cultural climate— The political and social environment of an institution or a society.

Holistic— Not concerned with specific details but dealing with the whole person.

Reliability— Reliability is a characteristic of a measurement/test, involving consistency of measure.

Validity— Measurement validity refers to whether a test is measuring what it claims to.

Resources

BOOKS

Cochrane, A.L. Effectiveness & Efficiency. Royal Society of Medicine Press, 1999.

Gibson, P, L. Irving, R., and R. Wood-Baker (eds.). Evidence-based Respiratory Medicine. Bmj Publishing Group, 2005.

Hamer, S. and G. Collinson. Achieving Evidence-based Practice: A Handbook for Practitioners. Bailliere Tindall, 2005.

Janzen, C., O. Harris, C. Jordan, and C. Franklin. Family Treatment: Evidence-based Practice with Populations at Risk. Wadsworth Publishing, 2005.

Levin, R.F., and H.R. Feldman (eds.). Teaching Evidience-based Practice in Nursing: A Guide for Academic and Clinical Settings. Springer Publishing Co., 2006.

Lobiondo-Wood, G. and J. Haber. Nursing Research: Methods and Critical Appraisal of Evidence-based Practice. C.V. Mosby, 2005.

Sackett, David. Evidence-Based Medicine. How to Proactice and Teach EBM. Second edition. Churchill-Livingston, 2000.

ORGANIZATIONS

National Center for Biotechnology Information (NCBI), US National Library of Medicine, 8600 Rockville Pike, Building 38A, Bethesda, MD 20894. (301) 496-2475. www.ncbi.nlm.nih.gov

Evidence Based Practice Resource Center, Oncology Nursing Society, 125 Enterprise Drive, Pittsburgh, PA 15275. 866-257-4ONS, 412-859-6100. www.ons.org, http://onsopcontent.ons.org/toolkits/ebp/index.htm

Agency for Healthcare Research and Quality, Gaither Road Rockville, MD 20850. (301) 427-1364. http://www.ahrq.gov